State of the Union: Vein Care Today

An interview with Danielle Bajakian, MD, vascular surgeon and Director of the Columbia Vein Program.

In our last interview, Dr. Bajakian walked us through how vein care had transformed from lengthy surgeries to quick, office-based treatment, often done in under 20 minutes, without a single stitch. Two years later, she’s still leading that transformation. In this follow-up, she shares how the Columbia Vein Program continues to refine these minimally invasive techniques, expand access, and push research forward.

What’s changed since last year’s update?

It’s been an exciting couple of years in vein care. We continue to refine office-based approaches for venous disease across the board; most of what I do still doesn’t require an operating room, but we’ve gotten even more precise in how we decide who’s a candidate for each type of therapy. Most are still catheter-based, with sclerotherapy or even lasers.

I’ve said before, and I say it all the time, we look at the entire venous system. Ultrasound mapping has become so detailed that we can individualize treatment based on vein size, anatomy, and symptom pattern. That allows us to treat earlier and so much more comfortably, while maintaining long-term durability.

Are there new technologies you’re using or evaluating?

Yes. We’ve added a few non-thermal, or non-tumescent, options that don’t rely on heat or multiple injections of anesthesia. For example, the adhesive glue therapies are now available in improved formulations and are easier to deliver into the vein, and we’ve been using them more often for patients who are particularly needle-averse or have pain sensitivities. We’re also evaluating mechanochemical ablation devices—technologies that mechanically disrupt and close the vein without heat—which can be a great fit for certain anatomy. This is why it’s so important to look at veins systematically and to talk to our patients about how they live and spend their time, the kinds of stress their bodies may be under day to day.

You mentioned stenting for May-Thurner Syndrome last year. Has that changed?

It has, both in how we identify and how we treat it. We’ve become more proactive about looking for iliac vein compression in patients who have recurrent swelling or pain that doesn’t match the extent of their superficial disease. Imaging has improved, and we now use intravascular ultrasound in many of these procedures to get a more accurate look at the vein walls. The stent technology itself has also advanced—newer stents are more flexible and better sized for venous anatomy.

What about procedures in the office—has recovery gotten even easier?

Yes, absolutely. Our patients are in and out quickly, often within 20 to 30 minutes, even for bilateral treatments. They walk right out afterward, and most return to work or exercise the same day. We’ve streamlined everything, from anesthesia to post-procedure care, so patients spend less time in recovery and more time back to their normal lives.

How do you help patients prevent recurrence or progression?

Education and consistency are key. We emphasize walking, calf-muscle exercises, avoiding prolonged standing or sitting, and using compression therapy when appropriate. That’s what often causes superficial venous insufficiency, making legs achy and tired. And potentially if the pressure increases in these veins, varicose veins too.

The newer compression garments are genuinely comfortable; I use them! Breathable fabrics with lighter weaves that don’t give you that itchy feeling. My patients want to wear them. We also follow patients long-term, because venous disease is chronic. Our goal is always to manage the disease, not just fix one vein.

You’ve said before that many patients don’t realize their symptoms are venous. Has that changed?

We’re getting better at recognition, but many people still think of leg heaviness or swelling as “just part of getting older” or “standing all day.” We’ve done a lot of outreach to help people understand that those early, subtle symptoms like fatigue, itching, restlessness at night often mean the veins aren’t working properly. The earlier we intervene, really the better the outcomes. And the better you feel, quickly.

What about research and the future of deep vein disease?

This continues to be an area of active investigation. We still don’t have an ideal way to repair or replace faulty valves in the deep venous system, but that’s where research is headed. There are exciting trials exploring bioengineered or artificial valves that could restore true physiologic flow rather than just relieving symptoms. At Columbia, we’re participating in studies that look at new endovascular valve technologies and imaging tools that could guide those procedures.

How does your team handle more acute issues like Deep Venous Thrombosis (DVT)?

We’re very aggressive in identifying and treating acute clots early. For extensive or iliofemoral DVTs, we often use catheter-directed thrombolysis or mechanical thrombectomy to remove the clot and reduce the risk of long-term complications like post-thrombotic syndrome which happens with chronic DVTs.

In many of those cases, intravascular ultrasound helps us identify compression or scarring that may need a stent as part of the same procedure. The tech really keeps getting better and it has made us both safer and more effective.

Are you seeing changes in insurance coverage for these therapies?

There’s still variability, but we’ve made progress. Our team works very closely with insurance providers to document medical necessity and ensure patients aren’t paying out of pocket for symptomatic disease. I’ve said it before, but having an academic center with a dedicated vascular authorization team makes a big difference—we’re often able to get newer therapies covered when the evidence supports them.

And what are your goals for the next few years?

We’re focused on three things: continuing to offer the latest technologies, expanding access in our community, and building on our research in deep venous disease. I also want more people in Washington Heights and across the city to know that these treatments are accessible, covered by insurance in most cases, and life-improving. And there are people who are dedicated to vein care in a serious way, leading the field, ready to take care of them.

Venous disease might not be life-threatening in general, but it absolutely affects how people move, feel, and live. And we can make a huge difference there.